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Monday, December 27, 2010

Saving eggs

Recently when I was stuck waiting for a doctor's appointment, I started reading a magazine article about IVF and I was fascinated. The article talked about IVF isn't an experimental treatment anymore, and how women in their thirties are storing eggs for a time when their lives are more amenable to childbearing. And how you can even store a slice of your ovary for future access to hundreds of eggs.

Of course, I couldn't help but think of how this might apply to women in medicine. I'm sure there are tons of women who shy away from competitive fields like surgery because they don't want to spend their prime childbearing years in rigorous training. Egg storage sort of evens out the playing field between men and women, but I don't think it's very mainstream right now... I don't know of any women who have done it. I remember on Sex and the City, Miranda gets heckled by her date when she brings up the idea of storing eggs. (Although that was admittedly a decade ago and also, I don't even watch that stupid show, much less have seen each episode multiple times.)

Personally, for a risk-adverse person such as myself, I don't think if I could do it. The article said that for a woman under 35, harvesting eight eggs only gives you a 50/50 shot at pregnancy. Plus there are hormones involved, which scares me a bit. Then again, I never wanted to be a surgeon and really had no compelling reason to delay having kids.

The other issue is the cost. I have a friend whose wife is (unfortunately, unsuccessfully) going through IVF right now, and he's informed me that the cost of IVF has trumped all the daycare costs I'd been complaining about. Insurance doesn't generally cover IVF, but there are arguments why it should. Women implant more embryos when they know then only have one or two shots at success due to cost.... this results in multiple pregnancies, which ultimately results in higher medical costs.

Before I say anything (else) that will surely be construed as judgmental (smiley face), I'll throw the question out there:

Would you consider saving your eggs for the purpose of use in the future?

34 comments:

Where I live, IVF is now covered by the government (you can try 3 times, and only one embryo is implanted at the time, if I'm not mistaken). It was quite the hot topic here a few months ago, before it became covered... Not sure it was a good move, both for financial and societal reasons.

Having been infertile, having had to consider IVF, and having seen friends go through futile cycle after futile cycle, I think that articles such as the one you describe are foolish at best, criminal at worst.

Age not only affects the quality of your eggs, but your whole reproductive system. Even with egg donation, older women may often fail to achieve pregnancy.

Maria: Part of the reason I made this post is that when I previously made a post about the reasons why I had children earlier (http://www.mothersinmedicine.com/2010/10/my-experience-with-infertility.html), some people got upset and said that it was ignorant of me not to consider that women have more options now to wait. I quote the following comment from that post, paraphrased slightly for length:

"So we no longer HAVE to have kids early... Or we can postpone & probably with the assistance of technology, have a child later in life. The beauty of it is, we can choose each of us for ourselves – at least in most developed, forward thinking countries. Being perplexed by women wanting to wait until they're established in the career seems a tad....for lack of a better word...ignorant. Yes there are fertility problems as you get older, but there are also many more options (costlier, but there nonetheless) to have kids as an older mom."

Except now it seems like nobody here is terribly excited about IVF and assisted reproduction for older women. I'm a little... um, what's the word? Oh yes: perplexed!

One benefit to saving eggs ahead of time if IVF is likely in your future, is that you don't have to go through the process of being stimulated and having eggs harvested before doing IVF. So, it makes that part of the procedure easier. Less shots in the butt.

Also, one aspect that gets lost in a lot of these conversation is that, in the case of pregnancy with extreme multiples (3 or more), many women will choose (and many practices will actually require) selective reduction.

Quadruplets plus may seem like the norm in reality TV, but they are not a required consequence of IVF. It's actually more common after Clomid (with hyperstimulation) + IUI than IVF.(That's what happened to Jon & Kate). And, they don't just increase medical costs. They increase miscarriage / stillbirth / extreme prematurity. Many women do not want to risk all of the potential babies' survival trying to hold on to all of them. Some will. It's something that definitely should be thought about before even beginning the process, and many fertility specialists require that patients sign an agreement that they will do a selective reduction if they have extreme multiples. Not sure how enforceable those agreements are, but still.

This is all an extremely privileged discussion. We are lucky as physicians and future physicians to have these resources and options available to us. When I was pregnant (opposite end of the spectrum for me - unplanned, in pre-med), I had to scramble to get medical coverage, and got refused maternity leave, and was lucky to get free childcare from relatives when I had to return to work almost immediately. These are tough decisions, but let's not lose sight of how privileged they are. Many women can't afford any sort of fertility treatments, and those who are lucky to have health insurance may not have one that covers it.

I wouldn't do it. To me the procedure is still so risky and the chances are too low. Plus, I'm with Action Potential's boyfriend. I don't want to be an old parent. I want to still be able to get down on my hands and knees and play with the kids.

MomTFH: I agree it's a privileged discussion, but if we're specifically talking about women who put off having children to further their medical careers (or other high power careers), these are all women who are probably going to be able to afford IVF. So it's sort of part of the nature of the discussion :)

I think it's an interesting question though to whether you would want to put off childbearing with the knowledge that IVF will very likely be in your future.

Regarding the multiples, I won't get into he controversy of selective reduction. But nobody would ever consider reducing, for instance, twins, but I suspect medical costs are significantly higher even just for a twin pregnancy than a singleton. (I don't know for sure if this is true, but I think there are more complications in twin pregnancies, most twins are born early and frequently require a NICU stay.) If just one or two embryos could be implanted at a time, then the cost could be reduced.

ActionPotential: I'm not sure what you mean when you say that the cost would be "worth it" after 15 years?

It's not like the Hybrid we just bought, where we'll make back the extra cost of the car in a few years. Childcare costs $X no matter when you do it. The question is, will you be paying the two college tuitions when you're 50 or when you're 60? But it's going to happen eventually.

AP: Interesting. I actually think of it the opposite way. I feel like it's easier for me to take some extra time now, at the beginning of my career, rather than later, when I've taken on more responsibilities. Once you have a busy practice, it may be difficult to cut back and your partners may not like it. Then again, it probably depends a lot on what field you're in and what sort of job you take.

Hmm, this reminds me of a Robert Heinlein book from years ago. In the book couples freeze their embryos right after conception and uncork them after they've secured their careers, etc. Another case of science fiction becoming real. As for me, no input--my kids are grown.

I think this article is a thinly veiled piece of advertising, false advertising at that. Which magazine did you read it in out of interest?

It is a definite medical advance that egg storage is becoming a real possibility but as others have mentioned assisted reproductive technology is not an assurance that you will get a child and people should make an informed decision.

Recently a friend of mine went through chemo aged 28 years for breast cancer. Egg storage would have been a godsend for her as she had to talk to her newish boyfreind about putting some embryos away for later, just in case. Happy to report that she and the boy got married and fell pregnant natuarally and are now expecting their second, but a trip to the fertility clinic early in their relationship, paired with chemo, surgery etc was a pretty big challenge.

Another friend, a doctor, is 33 and still yet to meet Mr Right. She is starting to get very down that she might not meet them in time. Egg storage might help her to take the pressure off which is making new relationships challenging for her.

But choosing egg storage so you can have your kids later is a vexed issue. It would be a significant financial outlay so who's responsible if it "doesn't work". Do you get a refund? Obviously these are ridiculous questions but I envisage that these issues would be very real if someone had invested considerably in fertility insurance only to find it wasn't as easy as that.

Australia doesn't transfer multiples, with most clinics only using one, maximum two so reduction is a non issue here, but there are still increased risks in an "elderly primigravida >35years" (what a terrible term, but funny too, imagine another context where a 37 year old would be called elderly)

I think fertility treatment is a wonderful thing for people who need it, but I have yet to know anyone who didn't find the journey harrowing, whether or not they had the desired outcome. I am sure there are people who had very few problems but I don't think they are the majority. So advertising the technology as a wonderful alternative borders on irresponsible I think.

All that said, I am a prochoice doctor so if a woman asked me to refer her for egg storage I would. But I would try to ensure that it was a fully informed decision, thats trickier than it sounds I guess, aahh...its never easy is it?

Bekkles: I don't remember the magazine. I can't say the article was entirely positive. It did mention several negatives of IVF.

I am just surprised how many people are skeptical of IVF, considering when I made those other posts about not delaying childbearing, several people commented about how there are so many great fertility options for women who wait to have children.

I'm 24 and a graduating MD. I have decided to not even consider IVF. If I can't fall pregnant naturally, there are many motherless babies who can do with a good mother. If that won't work either, I am sure I can have a great life without having children.

So no, I don't intend to freeze my eggs. I don't share the Western belief that we should and could control every aspect of our life.

I don't for one second believe having a baby is any woman's right.

It's a privilege. A small wonder, if you like.

And about the women/children/career thing: since when are men incapable of doing the raising part? But then again I'm lucky enough to live in a part of the world where work-time regulations are more or less effective, I don't want to become a surgeon and by the time I'm 30 I'll be earning enough to be a single mum if 'Mr Right' hasn't popped along. If every woman in my family has had a baby after the age of 30, chances are I'll be able to as well.

I think, instead of potentially harming ourselves with the risks of IVF, society should become more accepting of (fairly) young mothers with careers, day care should be more available, and it's most definitely time for men to emancipate themselves at home.

Doctor Blondie sums up very well why I don't think covering IVF was a good move. As for the financial reasons, well our society isn't that "rich" and I don't think we can afford paying for that kind of service. Instead, we really should put that money [that we do not have] elsewhere (cancer treatment for example, in which we're waaaay behind the rest of the country. This is not acceptable in my opinion).

Finally, IVF conceived babies are more prone to prematurity. Working in a very crowded NICU, that scares me a bit... These so desired babies become very precious which means we have to do everything to save them. But to what price? Sure in terms of money, that is a whole lot, but that is not what matters most for me. It's rather the quality of life after they get of of the hospital (if they do) that bothers me.

Anyway, maybe if we had a different health care system (universal coverage here), it would be different. I don't know. As Dr Blondie stated, I don't think having a baby is a right, it's a privilege. And forcing nature this way can't be all that good. We'll see in the next few years the results of our decision. Hopefully it'll prove I was wrong!

My guess is that anon #1 is from Quebec. The government there just decided this year to cover various fertility services. I think the idea is that although the actual cost of IVF seems high ($10-15,000 or so in Canada), the real expense comes from multiple babies that are born preterm and end up needing lengthy NICU stays, and that cost goes into the millions of dollars. Even if you don't live in a country with universal health care coverage, you're naive if you think that you're not bearing part of that cost.

There was also an interesting study in the Netherlands that found that the cost of IVF is offset by the value that the person brings to society. Not to mention that you can't really put a dollar value on what a baby would mean to a couple that was struggling with infertility.

My opinion is that infertility is a medical condition. Maybe both your tubes are blocked from PID, or you have PCOS or whatever. We don't decline treatment of medical treatments in general because it's "forcing nature".

As to whether I'd consider saving my eggs, probably not because I think it's too late for it to be of any benefit to me. At the age when we're planning to start trying, my odds are more than 50/50 anyway.

I'm with AP on "frontloading the career". I want to have paid off my debt and be financially stable before I have kids. I don't want to feel overly pressured financially, and I want to be able to focus on my kids rather than building my career. After two years of working, I'm going overseas for 4 months to do postdoc training which I wouldn't be able to do in Canada. I think if I had kids, it would be really hard to leave them for that amount of time and that's not what I would want anyway.

As a married intern in surgical field--planning on a fellowship, no less--I want to store embryos as soon as I can find the money to pay for it and the time to schedule/attend the required appointments.

Doctors are a risk-averse group, on average (that's part of why we order all those low-yield lab tests and scans, right? The ones we *know* are going to be negative before we send them...), and I'm just the same. Why would I risk not being able to have a child when I'm ready (in my 30s, once I'm finished with training), when there is technology available right now that could save me that trouble later on?

Doctor Blondie: I agree that having a baby is a privilege, but that's not why I think insurance should cover it. As someone pointed out, the real costs are when multiple babies are born due to too many embryos being implanted... and that IS covered by insurance companies. If insurance companies could cover the procedure and limit implantation, then money could actually be saved. And more importantly, there will be fewer premies.

Liana: I understand wanting to wait due to specific training goals that you wouldn't want to go through with a child. But I also think that waiting for the exact right time is a little futile, because there's never a right time. I always felt like after residency would be this golden time for childbearing, but I've discovered there are reasons why it's much harder to have a child post-residency.

JLlo: I order the tests because I don't want to get sued obviously :) I think contemplating having a child in surgery residency is just short of insane, so I think it's good that you have this technology to back you up.

No, I wouldn't. I'm 27 and I have two kids already, ages 5 and 8. I'm fairly certain we are done having kids because of KayTar's undiagnosed and possibly genetic medical condition and because I'm set on the path of medical training and balancing the two we already have is enough of a challenge. However, if we want to have another further down the road and can't by "traditional" means for whatever reason, we would be just fine with these being our only children. If we really want another, we could adopt.

I think just to clarify, I don't think there's a universal right time for everyone. I wouldn't say a blanket statement like it's better to have kids during residency, or it's better to wait. For myself, I can honestly say that residency would not have been the right time. My husband and I were living in separate cities, I had to travel and move multiple times a year (rural residency), we didn't own a house, my husband was establishing his own business, etc. Now I have a very flexible schedule, good income, and a supportive group practice.

I'll readily admit thought that I had the benefit of finishing residency when I was 27, and if I'd done a 5 year residency plus a year of fellowship, I might feel differently.

Liana: In this country, 27 is extremely young to be done with residency. Even if a person goes right from college to med school then does the absolute shortest residency, they would be 29 at graduation. Most people take some time off or do longer residencies or fellowships, so it's not at all unusual to finish training in the mid-30s.

Liana: infertility due to PCOS or PID is a medical condition. Infertility due to simply being 40 is nature.

I'm not postponing pregnancy till I'm finished with all my training. It's going to be tough anyway, and I'll have more financial security than most of my peers simply because I start off earning more than they do when they start having children.

I'm just worried I won't find a potential daddy for them. So to speak.

Fizzy, I'm aware of that. It's similar in Canada too (except that there are two 3-year med schools, one of which will accept you with only 2 years of undergrad, and family med residency is only 2 years), which is why I pointed out my age when I finished. Still, I think maybe similar to you, infertility always lingers in the back of my mind. My mom had fertility problems too. I honestly don't know what I would do if I started trying next year and 2 years passed without us getting pregnant. I probably would consider IVF. Maybe I would regret not paying to store my eggs. I hesitate to speculate though until I'm actually in that situation.

Doctor Blondie, I meant infertility before the 40s. I'm certainly not talking about covering IVF indefinitely for everyone. Not to mention, studies have shown limited effectiveness for IVF after the age of 43 (using donor eggs would be different obviously) and in Quebec it's not covered after that age. The thing is that when IVF is not publicly funded, it does become a privilege, and one that average couples are going to have to struggle to afford.

I do have a question for you about the adoption system where you are though... is it relatively easy to adopt? Because I've had friends navigate the adoption system in Canada, and it's been tough. There are long waiting lists (8 years for a healthy newborn through the public system), it's expensive if you choose to go private (10-15000$), and most birth moms select young couples. And I've also had friends whose birth mom changed their mind at the last minute and decided to keep the baby instead which was heartbreaking for them.

I don't think I would store my eggs. I think I would try to have kids when I was ready, and then if I still really couldn't, would probably adopt. In my faith we believe that life begins at conception, and so I probably wouldn't even do IVF and all that if it means potentially having to terminate some embryos, and also with the possibility of having unused embryos. Fortunately it is relatively easy, albeit expensive to adopt in the US.

Liana: I live in Holland. While it seems to be relatively hard to adopt a Dutch child, (because there are few who can be adopted) I know of several families who aren't extremely well-off who have adopted children. You can get refunds and subsidies for adoption. http://www.adoptie.nl/Costs do run up to 16 000 euro's, and amount to about 7 000 for Dutch-Dutch adoptions too.

Costs for IVF/ICSI run up to 10 000 euros per successful pregnancy.

My god, we're talking about BUYING children.

The thing is, I'm considering adopting regardless of whether I have a child of my own. I could adopt a South-African baby (but to them foreign adoptions are the last resort, and they do race-match the child with the adoptive parents to allow them to adjust to SA society)

The beauty of it is, we can choose each of us for ourselves – at least in most developed, forward thinking countries.There was also an interesting study in the Netherlands that found that the cost of IVF is offset by the value that the person brings to society.

Hmm. Went straight thru then 3 years residency 3 years fellowship. I was 30. We worried about fertility but have been blessed with 3 by age 38. Would we have done IVF? Maybe but more likely we would have adopted.

What you are seeing here Fizzy is selection bias in that you have people responding who would not do IVF and choose adoption. If you are going back to your old post about whether women should choose to have their kids early rather than rely on these methods:most people may worry about delayed childbearing and infertility but they are usually hoping it will not be them. To change your life plan based on a possible issue is really hard. And you had Mr Right-some of us were single.

Maybe it is a fallacy to rely on these new techniques;but if medicine is what you love and you don't think a child in the midst of training oe whenever, that should be your choice. Everything you choose to do comes with a cost. Some take the pain early others late.

I think if adoption were easier, people might think differently about it. I think there's a lot of expense and heartbreak involved in adoption as well. Much like with infertility, I know people who have been really lucky with adoption and some people who have not been so lucky.

I do not think technology is good or evil, it is the way it is used that defines its morality. In one country I know of, IVF and PGD are covered if there is a known fatal or severe genetic disorder to screen for.

Storing eggs for 10 years for women who have not found Mr Right by age 35 might also make good medical and financial sense since the woman's natural resource could produce extremely deficient offspring. Perhaps it does make sense for insurance to cover this technology with checks in place for potential abuse.

Right now it is only the financially secure who can afford it in America, but those people are also the scientific guienea pigs while this technology is perfected so they are contributing to society on a whole as well.

I'm a 30y/o intern with a toddler. I wouldn't save my eggs for the future because I'm using them now. I'm not convinced that the technology is in place yet that would enable me to conceive or have as healthy a baby at a later date, as just getting pregnant at an earlier age would. Financial and career stability does not trump my fears about my own biological limitations.

I'd love to have another baby right now but internship's a killer so it'll have to wait another few years.

My decision to have a baby prior to residency was influenced by..

the infertility rotation I did in med school..

the reduction in risk for ovarian and breast cancers that having a full term pregnancy prior to the age of 30 and breastfeeding brings (esp with my family history)

baby trumps career..

higher c/s rates and complications with age..

and mainly..because I didn't know if I was going to be "that person" running into infertility problems starting at age 35

I'm the only female in my residency program with a child. Saving my eggs for the future doesn't seem worth it when I look at the risks involved with storing them..or just waiting until I'm older. My family is far away and my resident husband and I struggle with our schedules but we have a healthy baby that I carried and birthed without issue and breastfed for 14m.

I'm surrounded by brilliant 30 y/o female docs who want children, babies planned for the distant future. As a feminist, I find it ironic that those of us who want children may be limiting our choices or chances of a healthy pregnancy by waiting. No frozen eggs for me, thanks!

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